Common Bile Duct Exploration Research Articles

Pragmatic algorithm for management of common bile duct calculi in resource-limited settings in India.

Endoscopic retrograde cholangiopancreatography (ERCP) facilitates the removal of common bile duct (CBD) calculi by endoscopy. When ERCP fails, exploration of CBD is required for the clearance of CBD calculi. The optimum way for the exploration of CBD is by choledochoscopy. Dedicated flexible or rigid choledochoscopes are expensive and available only in few places in India. Since 1991, we subjected patients with suspected CBD calculi to ERCP, followed by laparoscopic cholecystectomy (LC). Patients in whom ERCP failed to clear CBD were subjected to open exploration of CBD using any easily available, suitable, straight rigid scope for choledochoscopy. Since March 1991, out of 8866 patients with cholelithiasis, 862 underwent ERCP. Ninety-six patients in whom ERCP failed to clear CBD underwent open exploration of CBD. In each case of exploration of CBD, choledochoscopy was performed using a straight rigid scope, either a cystoscope, paediatric cystoscope, hysteroscope or 5-mm laparoscopy telescope with a 5-mm cannula. The CBD clearance was complete in 95 patients, and one patient had an impacted calculus at the ampulla. CBD explorations were followed by choledochoduodenostomy, T-tube placement or suturing of choledochotomy. No residual calculi were observed after such exploration. From our results, we advocate the following algorithm for CBD calculi in resource-limited settings. Subject patients with CBD calculi to ERCP followed by LC. In case of failed ERCP, open exploration of CBD with choledochoscopy using any suitable rigid scope. Dedicated flexible or rigid choledochoscope is not essential. This approach is cost-effective and successful.

Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis

ObjectivesTo analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL). MethodsSingle-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect. ResultsA total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results. ConclusionsLCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Current Management of Choledocholithiasis-narrative Review Article

The most common management of choledocholithiasis involves the two-step method that involves the use of pre-operative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy in six weeks’ time. But since the introduction of laparoscopic surgery, laparoscopic common bile duct exploration has been used as a single step method to treat this condition. Another method involves intraoperative endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy in the same setting. As there is no consensus on management, we have conducted this review article to look at the various management options for choledocholithiasis.

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.

Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones

BackgroundCommon bile duct (CBD) stones commonly occur in cholecystectomy cases. Management options include laparoscopic common bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). While ERCP is mature, it has complications, and LCBDE is a proven alternative. This study evaluates the safety and efficacy of these treatments in elderly individuals aged 70 and older. MethodA retrospective study from January 2015 to July 2022 included 160 elderly patients (aged 70 and older) diagnosed with cholelithiasis and choledocholithiasis. Patients were divided into single-stage (LCBDE, n = 80) or two-stage (ERCP followed by LC, n = 80) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications and long-term outcome for systematic analysis. ResultWe analyzed 160 patients treated for CBD stones, comparing single-stage and twostage groups. The one-stage group had more female patients (57.5% vs. 37.5%) and a higher mean age (80.55 ± 7 years). ASA classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred post-ERCP in the two-stage group. Stone clearance rates (92.35% vs. 95%) and biliary leakage incidence (7.5% vs. 3%) were similar, as were post-operative complications and longterm recurrence rates (13% vs. 12.5%). ConclusionIn conclusion, our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating common bile duct stones in elderly patients. Consequently, the single-stage procedure may be considered the preferred treatment approach for this demographic.

Holmium Laser Lithotripsy in the Management of Difficult Biliary and Cystic Ductal Stones – A Case Series

Abstract Choledocholithiasis or common bile duct stone (CBDS) presents a unique challenge in the management of biliary stones. The clinical presentation of CBDS varies from asymptomatic CBDS, detected during the evaluation of gallstone disease to sinister presentation, like severe biliary pancreatitis. Asymptomatic liver function test abnormality, biliary colic, dilated common bile duct (CBD) on sonography for pain abdomen, and cholangitis are the part of the spectrum. Based on clinical suspicion and aided by laboratory parameters, the diagnosis is confirmed by modalities such as ultrasonography or magnetic resonance cholangiopancreatography or by endoscopic ultrasound. Endoscopic radiological cholangiopancreatography (ERCP) has evolved as a standard of care over the decades for the management of CBDS and surgical exploration of CBD is rarely resorted. ERCP is followed by laparoscopic cholecystectomy as a definitive treatment to prevent recurrence of CBDS. Multiple factors play a role in the successful extraction of CBDS. Two broad considerations are the size of stone and bilio-duodenal anatomy. Multiple studies have noted that stone size larger than 15 mm requires fragmentation for successful extraction. Mechanical lithotripsy has been cornerstone for the management of such cases. Besides size of stone, morphology and number of stones, narrow CBD (distal to stone), duodenal diverticulum and altered anatomy due to gastroduodenal surgeries pose a challenge in stone extraction and are collectively called difficult CBDS. Multiple modalities notably extracorporeal shortwave lithotripsy, holmium laser (Ho laser) lithotripsy, and electrohydraulic lithotripsy (EHL) have been studied for the fragmentation of large CBDS. Innovation in cholangioscopy and wider availability of peroral single-operator cholangioscope has brought EHL and Ho laser lithotripsy (LL) at forefront of management of difficult CBD stones. We share the experience of Ho LL for CBDS at a tertiary care hospital in Western India. The data of four patients, successfully managed with single-operator cholangioscopy (SoC)-guided Ho LL for indications ranging from large CBDS to residual large cystic duct stump stone has been discussed. These cases emphasize wider clinical application of SoC-guided Ho-LL beyond the size of the stone. Ho LL has revolutionized the management of difficult biliary stone. The major limitation is cost of care and availability of expertise.

Single-Stage Laparoscopic Common Bile Duct Exploration and Cholecystectomy Versus Two-Stage Endoscopic Stone Extraction Followed by Laparoscopic Cholecystectomy for Patients With Cholelithiasis and Choledocholithiasis: A Systematic Review.

Gallbladder stones with common bile duct (CBD) stones can be managed by a single-stage laparoscopic approach with transcystic or transcholedochal CBD exploration and cholecystectomy or a two-stage approach with endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction followed by laparoscopic cholecystectomy. Comparative outcomes between these approaches remain controversial. The objective was to compare single-stage laparoscopic CBD exploration and cholecystectomy versus two-stage ERCP stone removal followed by laparoscopic cholecystectomy for clearance of CBD stones, complications, length of stay, and costs.We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for randomized trials and observational studies comparing outcomes of interest between single and two-stage approaches. Meta-analyses using random effects models were conducted. Seven studies with 382 patients were included. The single-stage approach achieved higher stone clearance rates (OR: 1.53, 95% CI: 1.12-2.08) with a shorter length of stay (mean duration: 3.5 days, 95% CI: -5.1 to -1.9 days) compared to the two-stage method. No significant difference was seen in complication rates (45% vs 40%, p=0.43) or costs ($19,000 vs $18,000, p=0.34). For patients with gallbladder and CBD stones, single-stage laparoscopic CBD exploration with cholecystectomy appears superior for stone clearance while comparable in safety and cost to a two-stage approach. Further randomized trials are warranted.

Novel technique for laparoscopic common bile duct exploration using flexible videobronchoscope to study on clinical outcomes of single-stage (laparoscopic cholecystectomy and laparoscopic common bile duct exploration) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis - Prospective study in a tertiary care centre (BRACE study - BRonchoscope Assisted Common bile duct Exploration Study).

This study aimed to study on clinical outcomes of single-stage (laparoscopic cholecystectomy [LC] and laparoscopic common bile duct [CBD] exploration using flexible videobronchoscope) versus dual-stage (endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy) for cholelithiasis with choledocholithiasis-prospective study in a tertiary care centre (BRACE STUDY-Bronchoscope-Assisted CBD Exploration [CBDE] Study). Between April 2022 and April 2023, patients who underwent LC with laparoscopic CBDE and endoscopic retrograde cholangiopancreatography (ERCP) followed by LC participated in this single-centre prospective research. The Institute Ethics Committee granted its approval after receiving an ethical review. The primary endpoint of the proposed research was the removal of the gall bladder and CBD stones. The secondary outcomes studied were complications using the Clavien-Dindo score, cost-effectiveness, patient satisfaction score and post-procedure duration of hospital stay. A total of 168 patients were included in the study. The success rate of LC with laparoscopic CBD exploration using a flexible videobronchoscope (Group 1) was significantly higher as compared to ERCP f/b LC (Group 2) (96.4% vs. 84.5%, P value = 0.02). Out of the 84 patients in Group 1, direct choledochotomies were performed on 83 of them. Group 1 had a considerably shorter hospital stay (4.6 ± 2.4 vs. 5.3 ± 6.2 days; P = 0.03). Both the cost ( P = 0.002) and the number of procedures per patient ( P < 0.001) were considerably higher in Group 2. Major complications (Clavien-Dindo grade 3 and above) were significantly higher in Group 2 ( P = 0.04). Patient satisfaction in Group 1 scored more favourably than those in Group 2 (2.26 ± 0.3 vs. 1.92 ± 0.7; P = 0.006). For concurrent gall bladder and CBD stones, single-stage management by LCBDE using a flexible videobronchoscope has a significantly better primary outcome and lower major complications than dual-stage management. The single-stage strategy also has advantages in terms of a shorter hospital stay, the need for fewer procedures, cost efficiency and patient satisfaction.

Laparoscopic Common Bile Duct Exploration for Multiple Large Common Bile Duct Stones: A Case Report with Review of Literature

Endoscopic retrograde cholangio pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) in 2 different sessions, is the widely followed standard sequence of surgical procedures for concurrent gall bladder and common bile duct (CBD) stone disease, across the world. However, being highly technical, skillful and technology dependant, ERCP, sometimes, does not succeed even in the best of hands. This can happen due to abnormal local anatomy (eg. Previous Billroth II gastrectomy, previous surgical scars which distort the duodenum etc.) and unfriendly stone morphology such as a very large stone or a large number of stones. Failure to extract/retrieve bile duct stones at ERCP is an indication for CBD exploration (open or laparoscopic) at surgery. Herein, we present one such case of a 67 year old woman who had previously undergone surgery – laparoscopic cholecystectomy for gall stone disease 3 years back. She presented to us with a common bile duct loaded with multiple large stones. Inspite of undergoing ERCP (2 attempts over 48 hours), a common bile duct access could not be achieved endoscopically, thereby rendering endotherapy unsuccessful. She then underwent a successful totally laparoscopic CBD exploration, using standard laparoscopy instruments, some endoscopy accessories like endo-balloon &amp; dormia basket and intraoperative fluoroscopy.

Spare the Needle, Discharge the Child: Trending Post-Op Labs After Laparoscopic Common Bile Duct Exploration in Pediatric Patients Is Not Helpful.

Laparoscopic common bile duct exploration (LCBDE) utility in management of choledocholithiasis may decrease length of stay and patient cost, but postoperative management remains widely debated. We examined periprocedural LFTs for patients undergoing LCBDE and endoscopic retrograde cholangiopancreatography (ERCP) speculating for trend existence after successful LCBDE. We hypothesized that postoperative LCBDE LFTs would not downtrend even after successful ductal clearance. We identified 99 patients under 18 who underwent ERCP or LCBDE with at least one pre- and post-procedural LFT. Periprocedural LFTs between groups were compared using Wilcoxon signed-rank tests. The 22 ERCP patients demonstrated a significant downtrend across Tbili (P < .001), AST (P = .001), ALT (P = .002), and ALP (P < .001). The 27 LCBDE patients demonstrated a significant downtrend in Tbili (P = .002) only, while AST (P > .05), ALT (P > .05), and ALP (P > .05) were nonsignificant. Lack of consistent downtrend in the LCBDE group raises doubt regarding the utility of postoperative LFTs for post-procedural management.

Laparoscopic Common Bile Duct Exploration is a Safe and Effective Strategy for Elderly Patients

Laparoscopic Common Bile Duct Exploration is a Safe and Effective Strategy for Elderly Patients

A comparative study of laparoscopic choledocholithotomy with primary suture and T-tube drainage.

To investigate the clinical efficacy of laparoscopic choledocholithotomy with one-stage suture. The clinical data of 68 patients who underwent laparoscopic choledocholithotomy in our hospital from January 2015 to December 2021 were retrospectively analyzed. Among them, 29 patients underwent laparoscopic primary closure (PC group) and 39 underwent T-tube drainage (T-tube group). All patients were diagnosed with choledocholithiasis by B-ultrasound, CT or MRCP. The operation time, intraoperative blood loss, pain index, incidence of shoulder and back pain, postoperative satisfaction, postoperative bowel function recovery time, hospitalization time and expenses, and operation-related complications in the 2 groups were compared. 29 cases in PC group were successfully operated, and 39 cases in the T-tube drainage group (T-tube group) were successfully operated. The average operation time, postoperative bowel function recovery time, postoperative pain index, hospitalization time and expenses in PC group were significantly shorter or lower than those in T-tube group (P < .05) and the patient satisfaction in PC group was significantly higher than that in T-tube group (P < .05). In addition, the intraoperative blood loss and the incidence of surgical complications were similar between the 2 groups (P > .05). After laparoscopic common bile duct exploration, primary suture of common bile duct is a safe and effective treatment method, but the incidence of bile leakage is high, and clinical indications for surgery should be strictly controlled.

A single center experience of single-stage laparoscopic cholecystectomy and common bile duct exploration

A single center experience of single-stage laparoscopic cholecystectomy and common bile duct exploration

Single-stage laparoscopic cholecystectomy (LC) and common bile duct exploration (LCBDE) versus two-stage ERCP followed by LC for patients with concomitant Gallstones and CBD stones

Single-stage laparoscopic cholecystectomy (LC) and common bile duct exploration (LCBDE) versus two-stage ERCP followed by LC for patients with concomitant Gallstones and CBD stones

Laparoscopic common bile duct exploration as a single stage management for choledocholithiasis: a single centre experience

Laparoscopic common bile duct exploration as a single stage management for choledocholithiasis: a single centre experience

Early experience with Laparoscopic common bile duct exploration without T-Tube drainage at a tertiary care hospital in South India.

Early experience with Laparoscopic common bile duct exploration without T-Tube drainage at a tertiary care hospital in South India.

Single-incision laparoscopic common bile duct exploration and cholecystectomy: a case series

Single-incision laparoscopic common bile duct exploration and cholecystectomy: a case series

Perioperative outcomes and feasibility of Single-stage laparoscopic common bile duct exploration (LCBDE) and cholecystectomy with primary duct closure and internal biliary drainage for management of concomitant cholelithiasis with choledocholithiasis – a prospective surgical report from a university hospital

Perioperative outcomes and feasibility of Single-stage laparoscopic common bile duct exploration (LCBDE) and cholecystectomy with primary duct closure and internal biliary drainage for management of concomitant cholelithiasis with choledocholithiasis – a prospective surgical report from a university hospital

2-Port incision laparoscopic common bile duct exploration: experience in the Philippines

2-Port incision laparoscopic common bile duct exploration: experience in the Philippines

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.